EKG showed no acute changes. The patient was in sinus rhythm. A chest x-ray showed underlying chronic interstitial fibrosis, stable in appearance, slightly improved aeration, left base. No evidence of development or recurrence of consolidation or new infiltrate. On the CAT scan of her chest, the patient had pulmonary fibrotic changes and central lobar emphysema, hazy, ground glass opacities within the mid lung zone, perihilar region, bilaterally. Essentially unchanged in appearance from the prior study. There was no evidence of bronchiectasis or new focal consolidation or atelectasis. There was no pleural effusion. A 14 mm nodule in the left costophrenic angle, previously described mildly enlarged anteromedial mediastinal nodes were stable.

LABORATORY STUDIES: Showed hemoglobin 7.8, hematocrit 23.6, which remained stable during this hospitalization. White count of 6.4, 5.2, 7.2. Normal platelets from 286,000 to 350,000. There was no symptom of acute decompensation. Anemia was asymptomatic. His INR initially was 9.2 and then he received vitamin K x3 and subsequently INR came to 9.7, 7.5, 5.1 and 2.1. Microbiology data showed urine cultures with contamination as well as wound culture was VRE, which was sensitive to ampicillin, ceftriaxone, cefepime, imipenem, Levaquin as well as tobramycin. VRE was sensitive to ampicillin, but the patient has allergy to penicillin as well as cephalosporin, but most exclusively to Keflex.

LABORATORY DATA: Includes a white count of 10.6, hemoglobin 12.4, hematocrit 37.2, and a platelet count 190,000. Chemistries include a sodium 134, potassium 4.2, chloride 104, CO2 of 28. BUN 78 and creatinine 3.6; the initial creatinine was 4.2. Glucose 176. CPK 2024 today and it was 1880 yesterday with MB of 1.3 and a troponin of less than 0.06 and a troponin yesterday 0.6. The CPK from his prior admission was reportedly 312. Protime 11.2, INR 1.0, and PTT 24. Arterial blood gas shows a pH 7.38, PCO2 of 44, and a PO2 of 46 with an oxygen saturation of 79. It is unclear whether that was a venous stick as it does not seem to correlate with his clinical status. The patient had a CAT scan of the brain, which showed chronic periventricular ischemic white matter changes with no acute abnormalities seen. The chest x-ray from his prior admission showed no evidence of congestive heart failure and again today it shows no congestive heart failure, but evidence of cardiomegaly with a pacemaker defibrillator noted. A lung scan was done on the prior admission for similar problems and was low probability for pulmonary emboli.

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All personal information, including patient and physician names/dates/location, etc., has been deleted or changed, in order to maintain the highest professional standards of patient/physician confidentiality. Also, do note that the sample reports found on this site vary in terms of formats, depending on account specifics of various clients, and are part of this blog for informational and educational purposes only, and not intended to replace professional medical advice or opinions from qualified, licensed physicians.